TYPE Systematic Review
PUBLISHED 26 June 2023
OPEN ACCESS
EDITED BY
Frederick Ato Armah,
University of Cape Coast, Ghana
REVIEWED BY
Abraham Assan,
Global Policy and Advocacy Network
(GLOPLAN), Ghana
Tumaini Nyamhanga,
Muhimbili University of Health and Allied
Sciences, Tanzania
*CORRESPONDENCE
Helen Elsey
helen.elsey@york.ac.uk
RECEIVED 22 November 2022
ACCEPTED 11 May 2023
PUBLISHED 26 June 2023
CITATION
Elsey H, Abboah-Offei M, Vidyasagaran AL,
Anaseba D, Wallace L, Nwameme A, Gyasi A,
Ayim A, Ansah-Ofei A, Amedzro N, Dovlo D,
Agongo E, Awoonor-Williams K and Agyepong I
(2023) Implementation of the
Community-based Health Planning and
Services (CHPS) in rural and urban Ghana: a
history and systematic review of what works,
for whom and why.
Front. Public Health 11:1105495.
doi: 10.3389/fpubh.2023.1105495
COPYRIGHT
© 2023 Elsey, Abboah-Offei, Vidyasagaran,
Anaseba, Wallace, Nwameme, Gyasi, Ayim,
Ansah-Ofei, Amedzro, Dovlo, Agongo,
Awoonor-Williams and Agyepong. This is an
open-access article distributed under the terms
of the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction
in other forums is permitted, provided the
original author(s) and the copyright owner(s)
are credited and that the original publication in
this journal is cited, in accordance with
accepted academic practice. No use,
distribution or reproduction is permitted which
does not comply with these terms.
Frontiers in Public Health
DOI 10.3389/fpubh.2023.1105495
Implementation of the
Community-based Health
Planning and Services (CHPS) in
rural and urban Ghana: a history
and systematic review of what
works, for whom and why
Helen Elsey1*, Mary Abboah-Offei2 ,
Aishwarya Lakshmi Vidyasagaran1 , Dominic Anaseba3 ,
Lauren Wallace4 , Adanna Nwameme5 , Akosua Gyasi3 ,
Andrews Ayim3 , Adelaide Ansah-Ofei6 , Nina Amedzro1 ,
Delanyo Dovlo3 , Erasmus Agongo3 , Koku Awoonor-Williams7 and
Irene Agyepong3
1
Department of Health Sciences, Hull York Medical School, University of York, York, United Kingdom,
2
School of Health and Life Sciences, University of the West of Scotland (London Campus), London,
United Kingdom, 3 Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana,
4
Dodowa Health Research Centre, Research and Development Division, Ghana Health Service, Accra,
Ghana, 5 Department of Social and Behavioural Sciences, School of Public Health, University of Ghana,
Accra, Ghana, 6 School of Nursing and Midwifery, University of Ghana, Accra, Ghana, 7 Ghana Health
Service, Accra, Ghana
Background: Despite renewed emphasis on strengthening primary health
care globally, the sector remains under-resourced across sub–Saharan Africa.
Community-based Health Planning and Services (CHPS) has been the foundation
of Ghana’s primary care system for over two decades using a combination
of community-based health nurses, volunteers and community engagement to
deliver universal access to basic curative care, health promotion and prevention.
This review aimed to understand the impacts and implementation lessons of the
CHPS programme.
Methods: We conducted a mixed-methods review in line with PRISMA guidance
using a results-based convergent design where quantitative and qualitative
findings are synthesized separately, then brought together in a final synthesis.
Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using
pre-defined search terms. We included all primary studies of any design and used
the RE-AIM framework to organize and present the findings to understand the
different impacts and implementation lessons of the CHPS programme.
Results: N = 58 out of n = 117 full text studies retrieved met the inclusion
criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n =
3 were mixed methods. The geographical spread of studies highlighted uneven
distribution, with the majority conducted in the Upper East Region. The CHPS
programme is built on a significant body of evidence and has been found effective
in reducing under-5 mortality, particularly for the poorest and least educated,
increasing use and acceptance of family planning and reduction in fertility. The
presence of a CHPS zone in addition to a health facility resulted in increased odds
of skilled birth attendant care by 56%. Factors influencing effective implementation
included trust, community engagement and motivation of community nurses
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through salaries, career progression, training and respect. Particular challenges to

implementation were found in remote rural and urban contexts.
Conclusions: The clear specification of CHPS combined with a conducive
national policy environment has aided scale-up. Strengthened health financing
strategies, review of service provision to prepare and respond to pandemics,
prevalence of non-communicable diseases and adaptation to changing
community contexts, particularly urbanization, are required for successful
delivery and future scale-up of CHPS.
Systematic review registration: https://www.crd.york.ac.uk/prospero/display_
record.php?RecordID=214006, identifier: CRD42020214006.

KEYWORDS

Community-based Health Planning and Services (CHPS), health services administration

and management, primary care, public health, social medicine, urban health

1. Introduction milestones in blue, and the development of CHPS in green.

Globally there is a renewed interest and emphasis on
strengthening primary health care (1, 2). Yet, across sub–Saharan
Africa, primary health care is under-resourced, and attention
directed to prestigious central referral hospitals and vertical
programmes (3). There are few examples of national strategies
for delivery of primary and community prevention and care
that have developed from context-specific research to identify the
most effective approach. The Community-based Health Planning
and Services (CHPS), which has been national policy in Ghana
since 1999, is one such example (4). CHPS delivers community
level health promotion, prevention and primary clinical care
in Ghana’s multi-tiered primary health care system, to provide
the appropriate health services to communities, whilst supported
by a system of referrals to higher levels of care when needed
(5). The wealth of quantitative and qualitative assessments of
CHPS over three decades provide valuable insights into the
successes and challenges of the programme (6). Learning and
sharing these lessons is important not only for similar resource-
constrained countries across sub-Saharan Africa but is vital to
inform adaptations to the CHPS programme in Ghana itself,
particularly at a time of epidemiological and demographic
transition. Ghana, like all countries in sub-Saharan Africa is
experiencing rapid urbanization with an urban growth rate of
4.2 and 65% of the population is expected to be urban by
2030 (7). This is coupled with a rising prevalence of non-
communicable disease whilst still contending with infectious
diseases (8).
While there are still challenges in resourcing primary care
within rural Ghana, within-urban analysis highlights the inequities
in health outcomes, particularly for children aged under 5 years (9).
This highlights the need to improve the accessibility and quality of
prevention and primary care services for urban poor communities,
the majority of whom are dependent on often unregulated, private
providers (10).
The evolution of the CHPS programme in Ghana occurred
out of progressive national and health system learning over several
decades, with policy makers drawing on lived and research evidence
from these processes. Figure 1 shows key health policy development
Five years before independence, the Maude Commission of 1952
recommended health service development focusing on hospitals
and health centers resulting in an increase from 89 doctors and
three health centers in 1952 to 141 doctors and 46 health centers
by 1961 (11). The following 10-year health programme (1961–
1970) emphasized an efficient rural health service with integration
of hospitals and health centers, training of medics and paramedics
and intersectoral collaboration to tackle the social determinants
of health (12). Concerns however remained over the slow pace
of trickle-down of benefits to communities. Initiatives to reach
rural communities followed with the 1967 Kintampo Mark I
model of “cottage hospitals” and health posts (13) followed by
The Danfa Comprehensive Rural Health and Family Planning
Project (1972–1977) which developed a new cadre of community-
based workers known as Health Education Assistants (HEA) to
better reach rural communities. Evaluations showed that the HEA
approach improved adoption of family planning but struggled
to bring about changes in health practices when other support
services were not available (14–16). To address this the 1977/78
primary care policy emphasized community involvement with
the selection and training of village health workers, and the
introduction of Village Development Committees to stimulate
intersectoral collaboration (13, 17). Tiers from national through
regional, to district, sub-district and community were developed.
Later in 1978, 134 member states approved the WHO declaration of
Alma-Ata and the translation of the declaration into action resulted
in a plethora of uncoordinated initiatives at community level with
much emphasis on volunteerism and local support for community
health workers (CHW).
Ghana, like many other countries in sub-Sharan Africa,
was in a period of economic decline and stress throughout
the 1970 and 1980’s, and in 1985 started a World Bank
structural adjustment programme that involved significant out-
of-pocket user fees at point of service across the health
sector. The results were catastrophic for the poorest, many
of whom lived in rural areas in a country that though
progressively urbanizing, was still predominantly rural (18).
Senior policy makers were keen to reduce reliance on user fees
and community volunteers and find ways to enable patients’

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Elsey et al. 10.3389/fpubh.2023.1105495

FIGURE 1
The history of CHPS from its inception.

financial protection, address health systems weakness particularly The adoption of the Bamako Initiative under the leadership
at sub-district and community levels (19) and coordinate of UNICEF in 1987 presented an opportunity to address
donor programmes. these challenges. The initiative aimed to increase availability

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Elsey et al.
of healthcare services at community level, with essential drugs
supplied by donors slightly above cost-price with profits sustaining
future provision (20–23). Despite initial skepticism from senior
policy makers, the Ministry of Health (MoH) in Ghana began
implementation in six pilot districts in 1989. The district health
director and team developed a structured programme for selection,
training, support, and supervision of volunteer community health
workers who would be paid by medicine sales. At this time rural
areas were the focus as the most deprivation and need were found
here. The internal evaluation in 1992 highlighted the limitations
of relying on volunteers with ad hoc payment mechanisms based
on medicine sales. There was a realization that community-
based health workers integrated within the formal health system,
receiving a regular salary and with formal community health
nurse training were more likely to achieve success. This learning
paved the way for the Navrongo Community Health and Family
Planning Project (CHFP) where existing cadres of community
health nurses were redeployed from health centers and health posts
to live and work in the community, with responsibility for a wider
catchment population. Senior policy makers, understanding the
value of robust evaluation, ensured research became an integral
part of the design, implementation and evaluation of CHFP,
which became known as the “Navrongo Experiment.” Following
the initial 1994 pilot, the programme was launched in 1996
with a focus on bringing essential health services closer to the
communities, with particular emphasis on hard-to-reach rural
areas (5). Initial strategies involved retraining and deploying health
staff to communities, utilizing traditional institutions and support
structures to organize and mobilize communities, and providing
“doorstep” services such as preventive care, family planning, and
immunization services (24). This combination of health staff
deployment with community volunteer mobilization became the
recommended “Navrongo model.” Results demonstrated that the
strategies were both feasible and improved the primary health care
impact, particularly around child mortality and fertility indicators
(24–26). Construction of a compound in each community was
found to be essential, not only as a base for outreach and provision
of primary care services, but to provide accommodation for the
community health nurse. Within this rural context, land was
abundant and willingly provided by communities. Following a
successful replication of the strategies in Nkwanta in 1998, CHPS
was declared a national policy in 1999, with roll-out throughout
Ghana from 2000 onward, using Navrongo and then Nkwanta as
exemplars to inform scale up (5).
1.1. Components of CHPS: 15 steps and
milestones
Today, the key characteristics of the early Navrongo and
Nkwanta pilots remain, with community-based care provided by
a resident professional nurse known as a Community Health
Officer (CHO) supported by community volunteers, as opposed to
conventional facility-based and “outreach” services. A key strategy
for the successful introduction of CHPS in a community is close
engagement with the traditional leaders to ensure commitment
to the CHPS concept. This aims to trigger further community
Frontiers in Public Health
10.3389/fpubh.2023.1105495
participation and mobilization of volunteers, first to construct a
CHPS compound and then to support implementation of health
services. The process has been detailed in a series of 15 steps
to guide successful CHPS implementation (6, 27) (see Figure 2).
Services provided by the CHOs include household visits for
antenatal care, family planning services, and health education;
outreach clinics, providing child welfare services; and school health
services. In-service training workshops organized for CHOs serve
to improve basic clinical and midwifery services and develop
diplomacy, communication, and counseling techniques (6).
The careful evidence-based design, clearly specified features of
CHPS and national roll-out make it a prime subject for continued
evaluation, as can be seen by the many quantitative and qualitative
studies conducted since its inception. Learning the lessons from
these evaluations is vital if primary health care is to develop and
respond to the changing context within Ghana and beyond. In light
of this, we aimed to understand the challenges and facilitators to
the implementation of the CHPS programme and its impact on
health and process outcomes. To do this we conducted a systematic
review of published and unpublished empirical studies of the CHPS
programme to address the following objectives:
1. To describe the effectiveness of the CHPS programme in
improving health and health service outcomes.
2. To identify the extent to which CHPS has been able to reach
different population groups and geographical settings, both
rural and urban.
3. To describe the facilitators and barriers to implementation of the
CHPS programme and the maintenance of this implementation
over time.
The systematic review was performed according to the
Preferred Reporting Items for Systematic Reviews and Meta-
Analysis (PRISMA) statement (28).
2. Methods
2.1. Protocol and registration
The protocol for the review was registered on the
PROSPERO International prospective register for systematic
reviews (CRD42020214006).
2.2. Review design
We conducted a systematic review of published and
unpublished empirical studies on the CHPS programme in
both rural and urban areas in Ghana. To understand not only
which outcomes CHPS improves, but also for whom, in what
context and why, we conducted a mixed-method systematic review
using a results-based convergent design where the quantitative
and qualitative findings are synthesized separately and then
brought together in a final narrative synthesis (29). This allowed
us to collate quantitative results on the outcomes of CHPS
and qualitative, mixed-methods or quantitative results on the
mechanisms (e.g., health system, participant, or contextual factors)
that may influence effectiveness.
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Elsey et al. 10.3389/fpubh.2023.1105495

FIGURE 2
The 15 steps to CHPS implementation.

2.3. Inclusion and exclusion criteria
We included all primary studies of any design from both
published and unpublished literature that reported CHPS
implementation and evaluation in rural and urban Ghana.
Quantitative, qualitative and mixed methods studies that
evaluated CHPS spanning from 1994 (launch of the Navrongo
experiment, forerunner to CHPS) to March 2022 were eligible. See
Supplementary Table 2 for detailed description of the inclusion
and exclusion criteria.
International Development), The Doris Duke Charitable
Foundation, Columbia University; Royal Netherlands Embassy;
GIZ (Deutsche Gesellschaft fur Internationale Zusammenarbeit),
KOICA (Korea International Cooperation Agency), KOFIH
(Korea Foundation for International Healthcare), WHO (World
Health Organization), and CHAG (Christian Health Association
of Ghana).
2.5. Data screening and extraction

One reviewer (MA-O) conducted an initial screening of titles

and abstracts to remove any studies not conducted in Ghana.
2.4. Search strategy and terms
The remaining titles and abstracts of all identified studies were
screened by two reviewers. Screening was organized using Rayyan
An electronic search was planned on EMBASE (Ovid),
software (https://www.rayyan.ai/). Where insufficient information
MEDLINE (Ovid), PsycINFO (Ovid), Web of Science, and Scopus
was available in the abstract, full texts of papers were independently
and included studies from database inception up to October
assessed by two reviewers and any uncertainty resolved by a
2020, to identify relevant published and gray literature on CHPS
third reviewer. Data extraction was performed independently
implementation in Ghana. An updated search was conducted
by two reviewers using a standardized proforma, with any
in March 2022, using variants of the search terms associated
discrepancies resolved by a third reviewer. Variables extracted
with “Community-based health planning and services” and
include: Authors/year, Region/District of study (classify as urban
“Ghana” and “CHPS implementation” and “health outcomes”
or rural), aims/objectives, study design and methods, target
(see Supplementary Table 1). Both index terms and free texts
population, quantitative results and measures of health outcomes
were incorporated into the search strategy to make our search as
(e.g., child mortality, fertility, and maternal mortality) and any
sensitive as possible. We searched the reference lists of included
proximal outcomes (e.g., uptake of services, satisfaction, availability
studies, national CHPS annual reports from Ghana Health Service
of providers, and community involvement). Qualitative themes
(GHS), GHS policy, planning monitoring and evaluation reports,
were also extracted from findings and discussion sections.
and unpublished theses from the School of Public Health of
the University of Ghana. We drew heavily on the knowledge of
co-authors with long experience of CHPS to develop a list of
organizational websites to search for evaluations including: USAID 2.6. Quality assessment
(United States Agency for International Development), UNFPA
(United Nations Population Fund), JICA (Japan International As this review included all primary studies of any design,
Cooperation Agency), DfID now FCDO (Department for a number of quality assessment tools designed for specific

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Elsey et al. 10.3389/fpubh.2023.1105495

TABLE 1 Included studies with quality score.

References Focus/research question Region and urban/rural Study design and Sample Quality
Quantitative studies—plausibility trials, chronologically (n = 8)
Debpuur et al. (26) Impact of the initial 3 years of CHFP on Upper East, Rural 8,998 women (15–49 years) High
contraception and fertility

Phillips et al. (34) Demographic and health impact of Upper East, Rural 139,000 individuals High
CHFP with a view to scaling up results

Binka et al. (35) Demographic and health impact of Upper East, Rural 139,000 individuals High
CHFP with a view to scaling up results

Pence et al. (24) Impact of CHFP on under-5 mortality Upper East, Rural 52,801 children and 52,801 mothers High
during 1993–2000

Phillips et al. (36) Long-term impact of CHFP on fertility Upper East, Rural 47,036 women (15–49 years) Medium

Bawah et al. (37) Contribution of CHPS to mitigate Upper East, Rural 94,599 under-five children High
effects of poverty on childhood
mortality

Bawah et al. (37) Effect of GEHIP on under-5 mortality Upper East, Rural 7,044 under-five children and 5,914 High
and associated factors women

Asuming et al. (38) Family planning and unmet need Upper East, Rural 5,914 women (15−49 years) High
impact of GEHIP

Quantitative studies—other designs, chronologically (n = 19)

Awoonor-Williams et al. Exposure to CHPS and change in Oti, Rural Cross-sectional, 831 women (15–49 Low
(39) health-seeking behavior and health years)
knowledge

JICA (40) Project for the scaling up of CHPS Upper West, Rural Secondary data/programme evaluation, Low
implementation in region NA

Naariyong et al. (41) Comparing technical process quality of Eastern, Rural Cross-sectional, 600 mothers (15–49 Medium
ANC between CHPS and non-CHPS years)
areas

Aikins et al. (42) Evaluation of Facilitative Supervision Upper West, Rural Secondary data analysis, NA Medium
Visits (FSV) component of CHPS

Wood and Esena (43) Community utilization of CHPS Central, Rural Cross-sectional, 175 heads of Medium
households

Johnson et al. (44) Impact of CHPS on the uptake of skilled National, Rural, and Urban Secondary data analysis, 4,349 births High
birth care between 2003 and 2008

Awoonor-Williams et al. Monitoring systems to gauge CHPS Upper East, Rural Analysis of routine health service data Low
(45) coverage in all GEHIP districts

Ferrer et al. (46) HBC and CHPS implementation on Multiple, Rural Cross-sectional, 1,356 carers of children Medium
utilization, treatment and satisfaction under-5

Ferrer et al. (47) Effectiveness of iCCM and CHPS on Multiple, Rural Cross-sectional, 1,356 carers of children Medium
disease knowledge and health behavior under-5

Ferrer et al. (48) Cost-effectiveness of iCCM and CHPS Multiple, Rural Cross-sectional, 1,356 carers of children Medium
on diagnosis and treatment of under-5s under-5

Wiru et al. (49) Patronage of CHPS, factors associated Bono East, Rural Cross-sectional, 171 community Medium
with their use and challenges faced members

Sakeah et al. (50) Role of CHPS in women having PNC North East, Rural Cross-sectional, 650 women who had Medium
visits and factors associated delivered in the past 5 years

USAID (51) Quality and relevance of pre-service and Multiple, Rural, and Urban Cross-sectional, 401 majority CHNs, Low
in-service education of CHPS workers followed by enrolled nurses, midwives

Braimah et al. (52) Contribution of CHPS policy to Upper West, Rural Cross-sectional, 805 women Medium
women’s access to PHC services

GHS (53) Verification exercise to determine the National, Rural, and Urban Cross-sectional, NA High
functionality of all CHPS zones

Maly et al. (54) Access and quality of CHPS services Western, Rural Post-test, non-equivalent control design, Medium
after 2–4 years of project support 426 community members

(Continued)

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Elsey et al.
TABLE 1 (Continued)
References Focus/research question
Amponsah et al. (55) Process evaluation on MCHNP and
possible barriers to implementation
Kweku et al. (56) Relevance of community involvement
and community perception of CHPS
Kweku et al. (57) Community utilization and satisfaction
with CHPS services
Qualitative studies, chronologically (n = 26)
Nyonator et al. (58) Qualitative Systems Appraisal (QSA) of
why CHPS is implemented in some
districts, but stalled in others
Binka et al. (59) Independent, in-depth assessment of
CHPS progress
Ntsua et al. (60) Diagnostic appraisal of delivering family
planning services using CHPS model
Adongo et al. (61) Male involvement in family planning in
communities with and without CHPS
Awoonor-Williams et al. Lessons learned from CHPS scaling up
(63) in region where the pace has been much
more rapid than other regions
Baatiema et al. (64) Assessing participatory process in CHPS
Adongo et al. (61) Implementation challenges and lessons
from introducing rural CHPS
experiences to an urban environment
Krumholz et al. (65) Facilitating and constraining factors in
CHPS scaling up
Sakeah et al. (66) Extent to which CHO midwifery
program is integrated into CHPS
Sakeah et al. (68) Extent of community participation in
CHPS skilled delivery program
Atuoye et al. (69) Transportation barriers to access
maternal and child health services
Dalaba et al. (70) Effect of CHPS on reproductive
preferences and contraceptive use
Bougangue and Ling (62) Male involvement in various aspects of
maternal health care
Assan et al. (71) Barriers and facilitators of CHPS
through a systems-centric perspective
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Region and urban/rural Study design and Sample Quality
Eastern, Urban Cross-sectional, NA Medium
Volta, Rural Cross-sectional, 1,008 community Medium
members
Volta, Rural Cross-sectional, 1,008 community Medium
members
Volta, Rural Qualitative diagnostic approach, using High
focus group (19) with district managers,
sub-district health teams, clinic and
community-based nurses, community
leaders, men and women of
reproductive age
Upper East, Rural Qualitative, using desk review, in-depth High
and key informant interview, field visit
National, Rural, and Urban Qualitative, using desk review, in-depth High
and key informant interview and focus
group with CHOs, women (15–49 years)
and men in partnerships
Multiple, Rural Qualitative descriptive, using in-depth High
interview (62) with CHOs, CHVs and
health managers; focus group (12) with
male and female community members
Upper East, Rural Desk review of reports and qualitative Low
interviews with district and regional
directors
Upper West, Rural Spider-gram, using in-depth interview High
(17), focus group (2) and community
conversation with service users,
providers, community health committee
members
Greater Accra, Urban Analysis of routine health service data Low
(mainly women 15–49 years)
Upper East, Rural Qualitative, using in-depth interview High
(12) with key managerial staff current
CHPS system managers
Upper East, Rural Case study, using in-depth interview High
(67) with CHO-midwives, supervisors,
District Directors, heads of maternity
wards, tutors of midwifery schools,
health professionals, community leaders
and residents
Upper East, Rural Case study, using in-depth interview High
(12) with CHO-midwives
Upper West, Rural Qualitative, using focus group (2) with High
male and female participants, aged
18–70 years
Upper East, Rural Qualitative, using in-depth interview (5) High
with community chiefs and elders and
focus group (8 male and 8 female
panels)
Central, Rural Qualitative, using in-depth interview High
and focus group with married men,
CHOs, CHVs, and community leaders
Multiple, Rural, and Urban Qualitative, using in-depth interview High
(41) with national, regional, district, and
sub-district/local participants
(Continued)
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TABLE 1 (Continued)
References Focus/research question
Atinga et al. (72) How and why women and children are
disadvantaged in CHPS implementation
Nwameme et al. (73) Reactions of health care personnel on
implementation of CHPS in Accra
USAID (74) Formative research to adapt the CHPS
model to urban settings
Woods et al. (75) Contribution of CHPS to community
health sustainability
Yakubu (76) Factors (health service delivery,
socio-cultural, economic) influencing
utilization of CHPS
Amoah (77) State and functioning of CHPS from a
social capital perspective
Assan et al. (67) Challenges to achieving UHC through
CHPS
Kushitor et al. (78) Community perceptions, involvement
and how CHPS could be strengthened
Haykin et al. (79) Perceptions of non-physician health
workers on capacity to manage CVD at
CHPS facilities
Kweku et al. (80) Challenges, capacity development
priorities, and stakeholder perspectives
on improving CHPS
Kweku et al. (81) Responsibilities, motivations, and
challenges of CHPS community health
management committees
Wright et al. (82) Community perceptions of gaps in
CHPS maternal and child health services
Bassoumah et al. (83) Challenges to implementation and
utilization CHPS
Sakeah et al. (84) Selection procedures and roles of CHVs
and CHMCs in CHPS
Mixed-methods studies, chronologically (n = 3)
Sacks et al. (85) Domains of community health nurse
satisfaction and motivation
Yeboah and Francis (86) Factors that facilitate or constrain
community participation in CHPS
Atinga et al. (87) Community capacity to participate in
CHPS implementation
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Region and urban/rural Study design and Sample Quality
Upper West, Rural, and Urban Case study, using focus groups (5) with High
community informants, in-depth
interview with clients (71), and staff (13)
Greater Accra, Urban Qualitative, using in-depth interview High
(19) with CHPS staff and officials
Multiple, Urban Unclear Medium
Upper West, Rural Qualitative, using in-depth interview High
and focus group
Northern, Rural Qualitative, using in-depth (25) and High
key-informant (5) interview and focus
group (12) with community members
and key informants
Ashanti, Rural Qualitative, using in-depth interview High
(11) and focus group (2) with younger
and older adults
Multiple, Rural and Urban Qualitative, using in-depth interview High
(41) with national, regional, district, and
sub-district/local participants
Multiple, Rural Qualitative, using focus group (20) with High
mothers and fathers of children under-5,
adolescents without children and
community leaders
Upper East, Rural Qualitative, using in-depth interview High
with 21 nurses and 10 nurse supervisors
Volta, Rural Qualitative, using focus group (4) with High
health workers and community
members
Volta, Rural Qualitative, using focus group (4) with High
CHVs
Multiple, Rural Qualitative, using focus group (53) with High
parents of children under-5, young men
and women (15–24 years)
Northern, Rural Qualitative exploratory, using in-depth High
interview (30) with CHOs, volunteers,
and women receiving postnatal care
Upper East, Rural Qualitative exploratory, using focus High
group (33) and in-depth interview (43)
with health professionals and
community members
Multiple, Rural Cross-sectional, survey of 205 rostered Medium
CHNs, qualitative interviews (29) and
focus groups (4) with selected CHNs
Central, Rural Case study, using interview and Medium
informal discussion with community
members, health volunteers, opinion
leaders, CHOs, CHPS coordinator and
Director of Health in municipality
Upper West, Rural and Urban Exploratory sequential mixed-methods High
study, using in-depth interview (13),
focus group (5) with key stakeholders of
CHPS, and cross-sectional survey of 420
households
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 TABLE 2 Reach, adoption, and implementation of CHPS by region∗ .
Frontiers in Public Health

Elsey et al.
Region References Population coverage and proportion of Utilization of CHPS Trained CHOs at Other staff and Proportion
functional CHPS# (year reported) CHPS zones CHVs training with CHMC
(functioning)
Ashanti GHS (53) CHPS zones with >5,000 population = 25.3% N/R Zones with trained Zones with trained 94%
With basic equipment = 15.2% CHOs = 31.4% CHVs = 75.3%
Functional CHPS = 7.8% (2018)

Bono East Wiru et al. (49) 12 Functional CHPS compounds sampled 12.3% said CHO absenteeism affected N/R N/R N/R
their use of CHPS

Brong Ahafo GHS (53) CHPS zones with >5,000 population = 22.8% N/R Zones with trained Zones with trained 97.4%
With basic equipment = 30.7% CHOs = 35.4% CHVs = 79.1%
Functional CHPS = 10% (2018)

Central Wood and Esena N/R Of 175 respondents, CHPS utilized N/R N/R N/R
(43) “Very often” by 2.9%, “Often” by 30.3%,
“Not often” by 66.9%

GHS (53) CHPS zones with >5,000 population = 22.3% N/R Zones with trained Zones with trained 86.1%
With basic equipment = 33.8% CHOs = 47.7% CHVs = 77%
Functional CHPS = 11.1% (2018)

Eastern Naariyong et al. Within Brim North District: 11/49 areas were CHPS zones N/R N/R N/R N/R
(41)

GHS (53) CHPS zones with >5,000 population = 17.2% N/R Zones with trained Zones with trained 95.7%
With basic equipment = 36.5% CHOs = 50.0% CHVs = 82.8%
09

Functional CHPS = 6.5% (2018)

Amponsah et al. N/A: only areas with functional CHPS sampled N/R N/R N/R Three of 10 zones
(55) had regular VHM

Greater Accra GHS (53) CHPS zones with >5,000 population = 48.5% N/R Zones with trained Zones with trained 67.7%
With basic equipment = 36.4% CHOs = 46.3% CHVs = 33%
Functional CHPS = 4.7% (2018)

Northern Ferrer et al. (46) N/R 11.8% (61/671) N/R N/R N/R

GHS (53) CHPS zones with >5,000 population = 21.1% N/R Zones with trained Zones with trained 95.7%
With basic equipment = 35.5% CHOs = 24.9% CHVs = 93.7%
Functional CHPS = 10.8% (2018)

Oti Awoonor-Williams By 2004, 30% of population exposed to CHPS N/R N/R N/R N/R
et al. (39)

Upper East Phillips (36) By 2008, CHPS (combined) scaled up in all CHFP arms—<50% N/R N/R N/R N/R

10.3389/fpubh.2023.1105495
in cell1 (Zurugelu) areas, <60% in cell4 (comparison) areas, 100%
in cell2 (nurse out-reach) and cell3 (combined) areas

GHS (53) CHPS zones with >5,000 = 9.1% N/R Zones with trained Zones with trained 97%
With basic equipment = 47.8% CHOs = 54.3% CHVs = 96%
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Functional CHPS = 45.4% (2018)

Asuming et al. (38) GEHIP increased coverage from 20 to 100% in intervention N/R 100% in intervention 100% in intervention N/R
districts districts districts

(Continued)
Frontiers in Public Health

Elsey et al.
TABLE 2 (Continued)

Region References Population coverage and proportion of Utilization of CHPS Trained CHOs at Other staff and Proportion
functional CHPS# (year reported) CHPS zones CHVs training with CHMC
(functioning)
Upper West JICA (40) 36% of target number of functional CHPS zones by 2015, N/R N/R 160 CHOs trained N/R
increasing from 24 in 2006 to 71 in 2009

Braimah et al. (52) 256 CHPS zones created as of 2017 N/R N/R N/R N/R

GHS (53) CHPS zones with >5,000 = 3.3% N/R Zones with trained Zones with trained 93.6%
With basic equipment = 55.2% CHOs = 83.2% CHVs = 97.5%
Functional CHPS = 55.9% (2018)

Volta Ferrer et al. (46) N/R 31.3% (228/685) N/R N/R N/R

GHS (53) CHPS zones with >5,000 = 17.9% N/R Zones with trained Zones with trained 79.3%
With basic equipment = 18.4% CHOs = 39.2% CHVs = 73.9%
Functional CHPS = 6.7% (2018)

Kweku et al. Central Tongu 15/18 demarcated CHPS zones were functional Central Tongu 53.8% N/R N/R N/R
(56, 57) Nkwanta South 21/25 demarcated CHPS zones were functional Nkwanta South 76.6%
Both districts 65.2%

Western GHS (53) CHPS zones with >5,000 population = 21.0% N/R Zones with trained Zones with trained 89.2%
With basic equipment = 39.1% CHOs = 45.1% CHVs = 72.4%
10

Functional CHPS = 13.2% (2018)

Maly et al. (54) Only CHPS zones (24) with physical structure were sampled N/R Mean 3 CHOs per CHPS N/R 22/24
zone (range 1–8)

National Johnson et al. (44) 2009–2011 CHPS zones doubled from 868 to 1,675 (functionality N/R N/R N/R N/R
not specified)

GHS (53) CHPS zones with >5,000 = 21.9% (national average CHPS zone N/R Zones with trained Zones with trained 89.8%
population = 3,821) CHOs = 42.4% CHVs = 76.2%
Of the 5,918 CHPS zones surveyed, 13% were considered
functional, 31.4% had basic equipment
∗ Bono, North East, Savannah, Western Northern–no quantitative results relating to adoption or implementation of CHPS from these regions [GHS (53) validation survey report presents results for national-level and by region, but not according to the new list

of regions].
# Functional CHPS means all steps completed except construction of compound, motorbike training, procure bicycle, procure drug kits and volunteer supplies.

10.3389/fpubh.2023.1105495
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Elsey et al.
study types were implored in assessing the quality of included
studies. Among them were The Cochrane risk of bias tool
(30), used to assess the quality of randomized controlled
trials (RCTs); ROBINS-I was used to assess risk of bias in
non-randomized intervention studies (31); and the risk of
rigor (32) within qualitative studies was assessed using the
Critical Appraisal Skills Programme (CASP) Qualitative Research
Checklist (33), see Table 1 for included studies and corresponding
quality scores.
2.7. Data analysis
In accordance with our results-based convergent design,
quantitative and qualitative findings were synthesized separately
and then brought together in a final synthesis (29). For quantitative
studies, effect sizes (Relative Risk, Odds Ratio, change in
means), sample sizes and potential moderators (e.g., population
characteristics) were summarized in tabular form. Due to the
significant heterogeneity of studies, and with many studies drawing
on the same longitudinal data set, we were unable to conduct
the planned random-effects meta-analysis to estimate the effect
size (and 95% confidence intervals) for each outcome. Instead, the
key parameters reported in each study are presented in Tables 2–
4.
Data from qualitative studies were extracted and analyzed
using the RE-AIM framework. The RE-AIM framework has been
used extensively (88) to evaluate public health interventions
and aims to understand not only effectiveness (E and our
objective 1), but also who is reached (R) by the intervention,
how far it has been adopted (A) in different settings and
by different health workers (addressing our objective 2), and
lessons on implementation (I) and maintenance (M) which
refers to the sustainability of the programme (addressing our
objective 3, see Figure 3). Segments (commonly sentences) within
the qualitative findings were coded against the five RE-AIM
domains independently by two reviewers and arbitrated by a
third reviewer. Once all findings had been coded, the segments
from each study were combined and reorganized under the RE-
AIM domains. Segments were then compared and where one
segment was clearly articulating the same issue as a segment
from another study, these were grouped together and assigned a
heading that represented all grouped and single segments. These
were color-coded to illustrate issues that occurred frequently and
less frequently in the synthesized findings. Issues occurring less
frequently should not be seen as less important, merely that
they were identified less frequently in published studies (see
Figures 5, 6).
Qualitative and quantitative findings from mixed methods
studies were included in the respective qualitative and quantitative
synthesis. Any meta-inference from mixed methods studies
was included in the qualitative synthesis. The final synthesis
of quantitative and qualitative data was conducted according
to the RE-AIM framework. We identified and confirmed
any key lessons, commonalities, and any contradictions
by returning where necessary to included studies and
quality assessments.
Frontiers in Public Health
10.3389/fpubh.2023.1105495
3. Results
3.1. Study selection and characteristics
A total of 8,376 records were initially identified through
the electronic searches with an additional 27 papers identified
through reference list screening and gray literature sources, of
which 2,225 were duplicates and removed. Following screening,
117 full text papers were assessed for eligibility, with 59 excluded
with reasons, leaving 58 papers included in the final synthesis
and analysis (see the PRISMA flow chart in Figure 4). The final
synthesis included 58 studies, 28 of which were qualitative, 27
quantitative, and three mixed methods studies. Details of the
quantitative findings are presented in the following tables: Table 2
presents a summary of the quantitative results relating to the
domains of Reach, Adoption and Implementation; Table 3 presents
quantitative results of effectiveness in improving child mortality
and fertility; and Table 4 presents effectiveness of other outcomes
measured in the included studies on family planning, maternal
and child health. Qualitative findings are integrated with key
quantitative results under the RE-AIM domains in the text below.
3.2. Study settings
The geographical spread highlights the uneven distribution
of studies assessing CHPS, with the majority conducted in the
Upper East Region, where the original Navrongo Experiment was
located (see Figure 5). While most studies focused on CHPS in
rural settings, some papers have assessed CHPS implementation in
urban areas, including three qualitative studies (51, 61, 73), and one
quantitative study conducted only in urban areas (55).
3.3. Adoption of CHPS within different
settings
3.3.1. Low functionality in remote rural and urban
areas
Guided by the RE-AIM framework, “adoption” refers to the
places and settings in which the CHPS programme is being
delivered and thus highlights geographical regions or types of areas
where adoption has been limited. Following the launch of the
national policy to scale up CHPS in 1999, there has been a focus
in the literature on increasing the coverage of the programme (see
Table 2). National level studies identified that between 2009 and
2011, functional CHPS compounds doubled from 868 to 1675 (44).
A process of declassification of “non-functional” CHPS zones
took place throughout the country in 2018. CHPS zones were
classed as non-functional when CHPS compounds were found to
be non-existent or essential staff and equipment were not available
(53). This was found to be particularly apparent in remote rural
areas, with the North East and Northern regions having only 22.
Four percent and 33.8% of CHPS zones functioning effectively
(53). Adoption was also challenging in urban areas, for example
in the Greater Accra region only 672 of the 834 zones were
termed “functional,” and only 539 of them had basic equipment to
11 frontiersin.org
 TABLE 3 Studies of CHPS assessing effectiveness in improving child mortality and fertility.
Frontiers in Public Health

Elsey et al.
References Context Intervention Fertility, parity Under-5 child Neonatal Infant mortality Early child Late child
Study design progression and mortality rate (0–59 mortality rate rate (0–11 mortality rate mortality rate
Sample contraceptive months) (first 1 month months) (0–23 (24–59
prevalence of life) months) months)
Debpuur et al. (26) Kassena-Nankana Arm 1: Volunteers Contraceptive prevalence NA NA NA NA NA
District and community rises from 3.4% in 1993 to
Pilot and 4-arm engagement 1999: Arm 1 (Vol) = 6.0%;
plausibility trial Arm 2: CHO Arm 2 (CHO) = 6.0%; Arm 3
phases (baseline located in sub (Vol + CHO, CHPS) = 8.2%;
1993 and district health Arm 4 (Comparison) = 6.0%
plausibility trial center <10 km from Total fertility rate dropped in
1996–1999) rural households all 4 arms
N = 8,998 women Arm 3: Both OR for parity progression
(15–49 years) volunteers and compared to Arm 4
CHOs (i.e., CHPS) (Comparison) from 1993 to
Arm 4: 1999: Arm 1 (Vol) = 0.81, p <
Neither/Comparison 0.05; Arm 2 (CHO) = 0.85, p
Analysis of < 0.05; Arm 3 (Vol + CHO,
Navrongo CHPS) = 0.77, p < 0.05
Demographic
Surveillance System
(NDSS) data to
assess impact on
family planning
knowledge, use
12

and fertility

Phillips et al. (34) Kassena-Nankana Same arms as above Fertility rate reduced by Arm 3 (Vol + CHO, CHPS) NA NA NA NA
District 15.0% in Arm 3 (Vol + CHO, = 224–100 deaths per 1,000
Plausibility trial CHPS) compared to Arm 4 person-years; Arm 4
with four arms and (Comparison). (Comparison) = 212 to 145
9 time points deaths per 1,000 person-years
between 1996 and No significant difference
2003 between Arm 1 (Vol) or Arm
N = 139,000 2 (CHO) and Arm 4
individuals (Comparison); 95% CI or
p-value not presented

Pence et al. (24) Kassena-Nankana Same arms as above NA (0–59 months) NA (0–11 months) (12–23 months) (24–59 months)
District Significant positive effect: No significant difference Significant negative Significant positive
Plausibility trial (1 Arm 2 (CH0) Rate Ratio = in before/after analysis in effect: Arm 1 (Vol) effect: Arm 2 (CH0)
July 1993−30 April 0.86 (95% CI = 0.74, 0.99) any arm. Rate Ratio = 2.35
2000) No significant difference in But greater declines seen (95% CI = 1.52, Rate Ratio = 0.61

10.3389/fpubh.2023.1105495
N = 52,801 before/after analysis: Arm 1 in Arm 2 (CHO) and 3.63) (95% CI =
children and (Vol), Arm 3 (Vol + CHO, Arm 3 (Vol + CHO, No significant 0.42, 0.88)
52,801 mothers CHPS) and Arm CHPS): difference in
4 (Comparison) Arm 1 (Vol) = −11%; before/after
Arm 2 (CHO) = −43%; analysis: Arm 2
Arm 3 (Vol + CHO, (CHO), Arm 3 (Vol
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CHPS) = −33%; Arm 4 + CHO, CHPS)

(Comparison) = −13% and Arm
4 (Comparison).

(Continued)
Frontiers in Public Health TABLE 3 (Continued)

Elsey et al.
References Context Intervention Fertility, parity Under-5 child Neonatal Infant mortality Early child Late child
Study design progression and mortality rate (0–59 mortality rate rate (0–11 mortality rate mortality rate
Sample contraceptive months) (first 1 month months) (0–23 (24–59
prevalence of life) months) months)
Phillips (36) Kassena-Nankana Same arms as Total fertility rate in impact NA NA NA NA NA
District above; further arms period (1995–2001): Arm 1
Plausibility trial, added in scale up: (Vol) = 5.01–4.40; Arm 2
assessed the impact Arm 5 (CHO) = 5.75–5.34; Arm 3
period (1995–2001) (Comparison for (Vol + CHO, CHPS) =
and CHPS scale-up scale-up): 4.94–4.33
period (2004–2010) Volunteer services Arm 4 (Comparison) =
N = 47,036 women added to Arm 4 5.06–4.89
(15–49 years) Arm 6: CHOs Significant difference between
added to Arm 4 Arm 3 (Vol + CHO, CHPS)
Arm 7: Volunteers and Arm 4 (Comparison) in
added to Arm 2 2001: Linearized hazard ratio
(CHO only) = 0.85 (95% CI = 0.79, 0.92);
Arm 8: CHOs non-significant in other arms.
added to Arm 1 In scale-up period
(Vol only) (2004–2010):
Arm 1 (Vol) = 4.24–3.59;
Arm 2 (CHO) = 4.94–4.72;
Arm 3 (Vol + CHO, CHPS)
= 4.03–3.71; Arm 4
(Comparison) = 4.69–4.07
By 2010, significant difference
between Arm 4 (Comparison)
13

and Arm 1 (Vol) = 0.88 (0.81,

0.96); and New Arm 7
(Volunteers added to CHOs)
= 1.11 (1.02, 1.21)

Bawah et al. (37) Kassena-Nankana As above four arms, NA All arms showed NA NA NA NA
District analysis of improvements, but only Arm
Plausibility trial Navrongo 3 (Vol + CHO, CHPS)
(January 1, 1995 to Demographic significantly improved
December 2010) Surveillance System mortality among the poorest
N = 94,599 under (NDSS) data to and least educated, over all
5 children identify relationship time periods:
between HR by 2008–2010
wealth/education Arm 1 (Vol) HR = 0.98, NS;
and child mortality Arm 2 (CHO) HR = 1.11, NS;
in the 4 arms. Arm 3 (Vol + CHO, CHPS)
Age-conditional HR = 0.67, p < 0.01; Arm 4

10.3389/fpubh.2023.1105495
proportional hazard (Comparison) HR = 1.00
analysis

Awoonor-Williams Nkwanta District Cross-sectional Adjusted risk ratio for CHPS NA NA NA NA NA

et al. (39) 2002 district level survey of CHPS and generating knowledge of
survey non-CHPS zones, modern contraception = 1.82,
frontiersin.org

N = 831 women using logistic p < 0.01 and for use of

(15–49 years) regression models modern contraceptives
to assess the effect among those who reported
of CHPS exposure knowledge = 3.33, p < 0.01
on health indicators

(Continued)
 Elsey et al. 10.3389/fpubh.2023.1105495

provide services (53). As a result of this declassification, the GHS

mortality rate

reported that by September 2019, there were 5,155 functional zones,

Late child

2,467 zones with compounds, and 3,160 with basic equipment

months)
(24–59

nationally (53).
NA

NA
mortality rate
Early child

3.3.2. Resources and leadership required for

months)

adoption
(0–23

Qualitative studies highlighted the facilitators and barriers

NA

NA
to adoption of CHPS within different geographical settings
(see Figures 6, 7). For under-served rural areas there were
control (HR = 0.72; 95%
No significant difference
Infant mortality

particular challenges due to the uneven distribution of CHOs

between GEHIP and

CI = 0.30, 1.79; p =

(67) and inadequate accommodation for CHOs (67, 72, 85),

rate (0–11

while recruitment of staff from the communities they serve

months)

aided adoption of CHPS in these areas (63). The majority of

0.480)

qualitative studies cited limited investment in the development of

NA

new CHPS compounds with insufficient supplies, equipment and

infrastructure to deliver CHPS services as a major barrier to wide
0.52, 95% CI = 0.28,
(first 1 month
mortality rate

neonatal mortality
by approximately

scale adoption. Authors explained this was due to a lack of financial

0.98, p = 0.045).
GEHIP reduced

one half (HR =

Neonatal

resources within Ghana’s health sector (58, 67) which impeded

of life)

actions to scale up CHPS from sub-district to national level (65).

Nyonator et al. (6) found that with some creative mobilization
NA

of resources, and particularly with political support, including

politicians contributing funds to CHPS, districts were able to
mortality rate (0–59

It is not possible to obtain an

because the mortality hazard

overall estimate of mortality

establish functioning CHPS zones (58, 63). However, when there

for all children under 5

was a low level of awareness of the principles of CHPS (including

Under-5 child

ratio varies by age

shared ownership between government and communities) (59),

and a strong political motivation for building CHPS compounds
months)

during local elections without ensuring they were equipped and

staffed (67), the zones were not able to function.
NA

modern contraceptives among

Contraceptive prevalence rises
by 64.40% in intervention and

between baseline and end line

7.60% in comparison districts

currently married women in

intervention vs. comparison
(2011–2015) aOR for use of

district = 1.79 (95% CI =

progression and
Fertility, parity

3.3.3. Socio-economic structures in urban areas

contraceptive

1.32, 2.44), p < 0.01

challenge adoption of the rural model

prevalence

Despite the potential strengths of the urban setting, such as

better roads and facilities suitable for referral of emergency cases
NA

(51, 74) challenges specific to the adoption of the CHPS model

in urban areas were found. These included the lack of traditional
leadership structures, lack of trust and limited home-visiting and
Intervention

seven contiguous

seven contiguous

engagement (51). These challenges were exacerbated by the fact that

treatment and

treatment and
Clusters: four

Clusters: four
comparison

comparison

staff often did not come from or live in the communities in which
districts

districts

they work (73), due to the difficulty in finding accommodation in

the area (51, 61). The need to pay volunteers due to the opportunity
cost they face (61), declining shared community values, particularly
2010, to test means

2010, to test means

Study design

N = 7,044 under-5
Upper East Region

Upper East Region

N = 5,914 women

among socially alienated young people (87), and a preference

GEHIP (A 5-year

GEHIP (A 5-year
trial launched in

trial launched in
of accelerating

of accelerating

for private facilities were also reported challenges. In addition,

(15–49 years)
5,914 women
children and
Context
Sample

a changing disease burden with increases in non-communicable

CHPS)

CHPS)

diseases and subsequent shifting demand for services by urban

residents raised further challenges to the adoption of the original
TABLE 3 (Continued)

model (61), particularly given CHOs do their field training only

Asuming et al. (38)

in rural CHPS zones (73). Nevertheless, attempts to adapt the

Bawah et al. (37)
References

model to link in with private facilities which could then become

CHPS outreach points for urban communities was identified as
a potential facilitator to the adoption of the CHPS model within
urban areas (51).

Frontiers in Public Health 14 frontiersin.org

Frontiers in Public Health
TABLE 4 Other outcomes: family planning, maternal, and child health.
References
Context
Study design
Sample
Debpuur et al. (26)
Kassena-Nankana District
4-arm plausibility trial
N = 8,998 women
(15–49 years)
Awoonor-Williams et al. (39)
Nkwanta District
2002 district-level survey
N = 831 women
(15–49 years)
Naariyong et al. (41)
Birim North District
15
2010 survey
N = 600 mothers
(15–49 years)
Johnson et al. (44)
National
2003 and 2008 Ghana
Demographic and Health
Survey (GDHS)
N = 4,349 births
Ferrer et al. (46)
Volta and Northern Regions
2014 household survey
N = 1,356 carers of
children under-5
frontiersin.org
Intervention
Arm 1: Volunteers and
community engagement
Arm 2: CHO in health center
<10 km from households
Arm 3: Both (CHPS)
Arm 4: Neither/Comparison
Analysis of NDSS data to
assess impact
Cross-sectional survey of
CHPS and non-CHPS zones,
using logistic regression
models to assess effect of
CHPS exposure on health
indicators
Cross-sectional survey of
CHPS and non-CHPS zones,
using logistic regression
models to assess effect of
CHPS exposure on health
indicators
Secondary analysis of GDHS
data with logistic regression
Models to examine the effect
of proximity to health
facilities and CHPS on use of
skilled care at birth
Survey conducted two and
eight years after iCCM in
Volta and Northern Regions
respectively, and more than
10 years of CHPS in both
regions
ANC
NA
Adjusted OR for CHPS
exposure and ANC attended
by health professional = 1.79,
p < 0.05
Adjusted OR for CHPS
exposure with: Full utilization
of ANC services = 2.73 (95%
CI 1.68–4.43), p < 0.001
Receipt of malaria
Prophylaxis = 3.73 (95% CI
1.73–8.04), p < 0.05
Tested for HIV
Infection = 4.49 (95% CI
2.37–8.51), p < 0.001
NA
NA
Delivery attended
by a medical
professional or
skilled birth
attendant
NA
Adjusted OR for CHPS
exposure vs. non-exposure =
1.79, p < 0.05
NA
Adjusted OR for uptake of
skilled birth care with
CHPS-only = 1.40 (95% CI
0.61–3.24), NS
For CHPS and health facility
within 8 km = 1.56 (95% CI
1.04–2.36), p < 0.05
NA
Elsey et al.
PNC Health knowledge Contraception
(including indicators
knowledge of
contraception)
NA OR for modern contraception OR for identifying source for
knowledge compared to Arm contraception compared to
4 (Comparison) from 1993 to Arm 4 (Comparison) from
1999: Arm 1 (Vol) = 0.72, p < 1993 to 1999: Arm 1 (Vol) =
0.05; Arm 2 (CHO) = 0.94, 0.67, p < 0.05; Arm 2 (CHO)
NS; Arm 3 (CHPS) = 1.28, NS = 0.60, p < 0.01; Arm 3
(CHPS) = 1.19, NS
Adjusted OR for Adjusted OR for CHPS NA
CHPS exposure and exposure and unprompted
PNC attended by knowledge of one or more
health professional family planning methods =
= 3.20, p < 0.01 2.12, p < 0.01
NA Adjusted OR for CHPS NA
exposure and index of
knowledge about pregnancy
danger signs = 1.17 (95% CI
0.69–2.00), NS
NA NA NA
NA Volta: Adjusted OR for carers NA
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to identify at least two signs of
severe diarrhea after messages
from CHPS = 3.6 (95% CI
1.4–9.0), p 0.02
Northern: receiving messages
from CHPS was not
associated with knowledge
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Elsey et al. 10.3389/fpubh.2023.1105495

3.4. Reach of CHPS

3.4.1. Variation in reach
Within the RE-AIM framework, “reach” focuses on the absolute

Crude OR for unmet need for

number, proportion and representativeness of individuals who

comparison district = 0.85

women in intervention vs.
among currently married
participate in or are reached by CHPS. Given the aim of CHPS

modern contraceptives
Contraception

(95% CI 0.64–1.12)
to increase access for all to health care, many of the quantitative
studies assessing CHPS have looked at overall coverage (see
indicators

Table 2) or utilization across the population through cross-sectional

household surveys. Findings varied across regions with rates of
NA

utilization of 76.7% in Nkwanta South Municipal (Oti Region)

and 53.8% in Central Tongu District (Volta Region) (56), whereas
Wood and Esena’s earlier study in Central Region found lower rates
Health knowledge

with 66.9% reporting rare use of CHPS (43). Ferrer found 11.8%
contraception)
knowledge of

in Volta region and 31% of the population in Northern region

utilizing CHPS for childhood illnesses (46). Johnson’s national
(including

analysis using 2003 and 2008 Demographic and Health Survey

data found only 9.9% of all births were in communities within
NA

NA

8 km of CHPS (44). Given the different methods, tools, and

target populations of these studies, results are not comparable,
62.3% had attended

but do indicate the variability of reach of the CHPS programme

PNC at least three
times (Bulisa =

across Ghana.
Mamprusi =
90.1%, West

34.5%)
PNC

NA

3.4.2. Inequities in reach

Studies identifying who in the population CHPS reaches were
skilled attendant during child
birth (Bulisa = 75.4%, West
66.3% were supervised by a
Delivery attended

more limited. While quantitative studies have explored whether

professional or

there is a social gradient in health improvements in CHPS areas

Mamprusi = 57.2%)
by a medical

(37), few studies quantified whether particular groups within

skilled birth
attendant

communities were more or less likely to be “reached” by the

programme. In the Upper East Region, ethnic and educational
differences were found to undermine equal reach, with women
NA

of the Nankana ethnic group significantly disadvantaged in

accessing CHPS for delivery compared to those within Kassena
having had at least four ANC
attendance (Bulisa = 93.1%,
87% of the women reported

communities, possibly due to the former’s more traditional beliefs

West Mamprusi = 80.8%)

about childbirth (66). Differences in reach to specific ethnic and

religious groups were also found in Nkwanta, with Christian and
Muslim women more likely to receive safe-motherhood care than
women who identified as traditionalists or with no religion (39).
ANC

NA

3.4.3. Reaching young people and men

seven contiguous comparison
Clusters: four treatment and
Survey conducted at CHPS

Further insights on “reach” from the qualitative studies

zones in both districts

include the observation that young people (78, 87) were

Intervention

frequently overlooked by the CHPS programme. There were mixed

findings on the ability of CHPS to reach fathers with several
studies identifying Father-to-Father Support Groups as a valuable
districts

mechanism for increasing male knowledge on health issues (72),

and male involvement being evident in family planning activities of
CHPS (45, 89). Others found the CHPS programme rarely reached
means of accelerating CHPS)
delivered in the past 5 years
Builsa and West Mamprusi

N = 650 women who had

men with many seeing the programme as a “women’s thing” (78)

launched in 2010, to test
2016 household survey
TABLE 4 (Continued)

GEHIP (A 5-year trial

and traditional gender norms around pregnancy and childbirth

Asuming et al. (38)
Study design

Upper East Region

N = 5,914 women

influencing the nature and level of male involvement in maternal

Sakeah et al. (50)
References

(15–49 years)

health and CHPS more broadly (62), and this was highlighted in
Context
Sample

family planning programmes in Southern Ghana (90). Reaching

Districts

particular groups of vulnerable individuals far from the CHPS

compound was a common challenge described in a number of

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Elsey et al.
qualitative studies, especially in relation to people with cardio-
vascular disease (79), and maternal health care where women
challenged the accepted notion that 5 km should be considered
walking distance when seeking maternal services without access to
good roads and any means of transport (69).
3.5. Effectiveness of CHPS
3.5.1. Mortality and family planning
Since the inception of CHPS, effectiveness studies have focused
on child mortality and fertility as primary health outcomes. Many
studies have also assessed key “process outcomes” such as uptake of
antenatal care visits and institutional deliveries, immunizations and
child health programmes (44, 46, 47, 55). Studies with a low risk of
bias reporting the effectiveness of the CHPS programme in health
outcomes are shown in Table 3. These studies all use data from
the Navrongo Demographic Surveillance System (NDSS) 1990–
2010 and compare four interventions implemented in Kassena-
Nankana district, Upper East Region: (1) Volunteers (Zurugelu),
(2) Nurse only, (3) Nurse + Volunteers, and (4) “unexposed” areas.
Three studies assessed under-5 mortality (24, 34, 37). The most
detailed analysis, which analyzed mortality over time and identified
interactions with wealth and education found under-5 mortality
improved over time in all areas, but Volunteers alone and CHO
alone benefitted the better off and educated. Only the combination
of CHO and volunteers significantly reduced under-5 mortality in
the poorest and least educated (37).
One study (24) assessed infant mortality but found no
significant difference between the four interventions from baseline,
but greater declines were seen in CHO (243%) and CHO plus
Volunteer areas (233%) than in the volunteer only (211%) and
comparison areas (213%).
Three studies used the NDSS data and four-arm trial design
to assess outcomes of family planning including change in fertility
rate (26, 34, 36). Given the context of Kassena-Nankana district
where the “fertility transition” had not begun in early 1990’s (i.e.,
3.4% in 1993), a rise in contraceptive use and drop in fertility rate
was found in all four intervention areas, but the odds of parity
progression reducing from 1993 to 1999 were highest in the CHO
plus Volunteer arm (see Table 3).
3.5.2. Maternal health
The results of studies reporting outcomes associated with
improved health are shown in Table 4. In Nkwanta district, the
presence of a CHPS zone was identified as increasing the odds
for delivery attended by medical professional [OR1 = 1.74 (p <
0.01), OR2 = 1.79 (p < 0.05)] and for postnatal care from a
medical professional [OR1 = 3.09 (p < 0.01), OR2 = 3.20 (p
< 0.01)] (39). Assessment of national DHS data found that the
presence of a CHPS zone in addition to a health facility resulted
in increased odds of care by a skilled birth attendant by 56%
(44). In Brim North, Eastern Region, CHPS exposure was found
to be positively associated with receipt of ANC (OR 2.73 (95% CI
1.68–4.43) compared to participants in non-CHPS areas and these
improvements in the provision of four ANC visits (75.4% in CHPS
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10.3389/fpubh.2023.1105495
compared to 72.3% in non-CHPS) from a trained provider (96.3%
in CHPS and 90.3% in non-CHPS) increased the odds of receiving
an HIV test and anti-malarial prophylaxis (41).
3.5.3. Child health
In terms of child health programmes, CHPS has been compared
with integrated community case management (iCCM) in the
Volta and Northern regions of Ghana. Differences in effectiveness
between the two interventions were found in each region with
health messaging from CHPS found to be associated with
identification of severe diarrhea by parents in Volta and prompt
care seeking in Northern Region (47). Cost-effectiveness analysis
found that appropriate diagnosis and treatment of malaria, diarrhea
and pneumonia were more cost-effective under iCCM than CHPS
in the Volta Region (48).
3.5.4. Accessibility and acceptance
Qualitative studies frequently highlight positive perceptions
of effectiveness of CHPS at community level, with respondents
acknowledging the programme’s significant role in making basic
health services more accessible for women and children, allowing
them to benefit from immunization, ante- and postnatal care,
health education, family planning, referral of severe disease
conditions and school health visits, in addition to improving health
outcomes in their respective zones (61, 73, 82).
Participants in several qualitative studies also highlighted the
critical role CHPS has played in changing negative perceptions
of some health services, particularly family planning, through
improved knowledge of the side effects of contraception (45, 60,
61). This increased acceptance of family planning was identified as
creating a shift in perceptions of the ideal family size, with spacing
births seen as desirable, although some women still reported
keeping their use of contraceptive secret from their husbands (70).
3.6. Implementation of CHPS: barriers and
facilitators
3.6.1. Trust and engagement
Both quantitative and qualitative studies identified barriers
and facilitators to the implementation of the CHPS model as
specified at design. Two inter-related themes that consistently
emerged across studies and settings was the need for trust
between CHPS staff and communities for smooth implementation,
and vital to this was strong community engagement (see
Figure 6). When CHOs lived within the communities they service,
these good relationships could develop (66, 71, 77). Volunteers
played a vital bridging role between CHOs and communities,
often facilitating implementation with their diplomacy skills,
as well as offering practical support by running errands for
CHOs and sometimes taking CHOs for home visits on their
motorbikes (60).
Community engagement organized through local leaders and
women’s groups to solicit their support for CHPS was frequently
identified as critical for effective implementation in the rural
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Elsey et al.
FIGURE 3
RE-AIM categorizations used in the review of CHPS studies.
studies (51, 57, 58, 63, 64, 68, 77, 82, 87). Where the engagement
component of CHPS were adapted sensitively to the local context,
implementation was more successful. For instance, in Nkwanta,
which has a more complex ethnic composition than the original
Navrongo communities, the engagement process was adapted so
instead of relying on traditional leaders to organize community
action in CHPS as had been done in the Navrongo model,
leaders were rather identified among elected officials, teachers and
clerics (45). A strong CHMC with membership able to resolve
any conflicts between health staff and community members has
also been identified as important for CHPS implementation in
such rural settings (61). One study that quantified community
engagement within the CHPSplus (CHPS+) intervention in
Volta region found that 48.9% of the 1,000 respondents were
actively involved, including through the identification of resources,
organizing durbars and preparing sites for outreach services, and
that involvement in these activities was associated with positive
perceptions of CHPS (80).
There was much consistency in the barriers to implementation
identified in the qualitative studies (see Figure 7) and the
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10.3389/fpubh.2023.1105495
majority cited limited community engagement as a key underlying
cause of poor CHPS implementation (58, 62, 65, 77). Lack of
engagement specifically led to CHMCs that were not sufficiently
active to provide the support and problem-solving needed for
implementation (53). Several studies identified low volunteer
motivation, particularly in urban areas, where communities were
not sufficiently engaged (73).
3.6.2. Organizational collaboration
Beyond the community level, effective implementation was
characterized by careful collaboration with diverse stakeholders
but particularly local authorities, religious organizations and
professional groups and associations. This helped to facilitate
ongoing operations such as establishing referral systems to higher
facilities, which promotes the use of CHPS services (66). The
importance of outreach services, particularly door to door services
has been identified by several studies as key for both delivering
services (60, 61), and also in building trust (56, 77).
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Elsey et al.
FIGURE 4
PRISMA flow diagram of the CHPS review.
3.6.3. Accommodation and logistics
From the health systems perspective, the most frequently
reported barriers to implementation were the lack of provision
of accommodation for CHOs, logistics and facilities to ensure a
functioning CHPS zone and this was found both in rural and
urban areas (51, 57, 65, 71, 73, 78, 82, 87). Lack of accommodation
for the CHOS within the community was a particular challenge
undermining both service delivery and the level of trust between
CHOs and community members (66, 77, 82). Within urban areas,
where land is scarce, this was a particular challenge with CHOs
having to commute into their areas of work (61, 73). In rural
areas, the recruitment of CHOs from outside the communities and
who may not therefore share a common language was identified as
undermining implementation both by CHOs and by communities
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10.3389/fpubh.2023.1105495
(85). The wider implications of limited resources were evident, with
the lack of motorbikes and provision of funds for their running
and maintenance undermining CHOs’ ability to undertake home
visits leading to more clinic-based static services and reduced trust
and engagement with households (59). Frequent stock-outs of
essential medicines including contraceptives was noted by CHOs
and women in the communities as a challenge that undermined
reliable service delivery (43, 70) with shortages of medicines
reported by 41.5% of survey respondents in Bono East Region (49).
3.6.4. Supervision, training, and referrals
Further health systems challenges were noted, particularly
the limited supervision from CHPS coordinators at sub-district
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Elsey et al.
FIGURE 5
Regional distribution of CHPS studies included in the review.
level and from higher levels (73). Cited reasons for this in both
rural and urban areas were the lack of available transport and
human resources (53, 65, 73). Referral systems were frequently
found to be lacking (57) and CHOs expressed a wish for further
training (85) not only in clinical skills such as midwifery (59) and
childhood illnesses (47), but also to improve support to volunteers,
planning and data collection (74). The limitations to facilities,
accommodation, resources, support and training were frequently
cited as a cause of the low motivation, with just over 50% of
CHOs stating they were satisfied with their role (85). Low levels of
motivation and negative attitudes among CHOs were identified as
a cause of favoritism and unequal treatment of clients, and affected
the effective implementation of CHPS (56, 77, 78). Subsequently,
a high attrition rate of CHOs was identified in several of the
qualitative studies (57, 72–74).
3.7. Maintenance of CHPS
3.7.1. Planning, budgets, and insurance
The RE-AIM framework defines “maintenance” as the extent
to which CHPS can be delivered sustainably for at least 6 months
or more following initiation. This domain allows exploration of
the extent to which CHPS has become institutionalized and part
of routine practice. The included studies identified several issues
that undermined the sustainability of CHPS services over time.
Low motivation and high absenteeism of CHOs, changing disease
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10.3389/fpubh.2023.1105495
burden, increasing demands and expectations of communities
beyond the prescribed service package of CHPS, linked with the
implementation issues identified above have all been identified as a
threat to sustainability of CHPS (67, 71, 72, 79, 82, 85). The non-
accreditation of elements of the CHPS programme, particularly
home-visits under the National Health Insurance Scheme (NHIS)
has also been identified as distorting delivery to favor clinic-based
services, therefore undermining the outreach and community
engagement components of CHPS in the long term (34, 60, 77,
82). Even where NHIS accreditation does exist, the delayed NHIS
reimbursement undermines continued delivery of service (53). The
changing disease burden has also been identified as a threat to
sustainability of CHPS (79, 82) and particularly the increasing
demands and expectations of communities beyond the prescribed
service package of CHPS (67).
However, more fundamental organizational issues were also
highlighted as barriers to CHPS maintenance, including a lack
of action planning, and more crucially limited budget, with the
Ministry of Health and GHS having no specific budgets to support
the CHPS programme (58), reportedly linked to a lack of high-level
political will and resource allocation specifically to CHPS (49).
3.7.2. Community collaboration and ownership
Conversely, in areas where CHPS has managed to engage
communities, particularly with strong support from traditional
leaders (56), integration within existing community structures that
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Elsey et al.
FIGURE 6
Facilitators from qualitative studies.
predated the establishment of CHPS in the community (64), and
initial community contributions to constructing CHPS compounds
(56, 68), CHPS programmes seemed able to flourish and sustain
activities. Similarly, where CHOs reported feeling motivated and
respected by communities and supervisors (66, 85), with basic
amenities provided in CHPS compounds (57, 66) and adequately
trained (53), CHPS services were maintained.
4. Discussion
CHPS is one of the few community-based primary care
and prevention programmes in sub-Saharan Africa that has
been shaped through pragmatic experimental research conducted
within the delivery context. The early studies from the Navrongo
Experiment show significant reductions in child mortality and
improvements in uptake of family planning. While the studies in
our review highlight many of the challenges in the adoption of the
approach across all locations and in implementation, where CHPS
was implemented according to the “15 steps,” delivery was more
likely to be successful.
So why is it so challenging to scale-up what is evidently a
successful approach? The literature on scale-up highlights the need
for both vertical scale-up i.e., institutionalization, and horizontal
scale-up i.e., increased coverage (91). Despite the initial skepticism
of senior health advisers in the Ministry following the signing of
the Bamako Initiative in 1989, the evidence from the Navrongo
Experiment convinced health leaders to turn the approach into
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national policy and so the process of institutionalization, or vertical
scale-up began.
Vertical scale-up has been identified as a pre-requisite for
increasing horizontal scale-up (92). A review of studies reporting
processes of scale-up by Milat et al. (93) has identified a number of
factors which are frequently associated with success. Interestingly,
many of these appear to have been present within the CHPS
scale-up process, including systematic use of relevant evidence,
strong leadership within the health sector and a well-defined scale-
up strategy. The launch of CHPS as a national policy in 1999,
and several subsequent reviews and revisions of the policy and
“Implementation Guideline,” the most recent of which took place
in 2016, make use of monitoring and research to strengthen
implementation. The development of CHPS training with the
clarity of the 15 steps and the six milestones are in-line with scale-
up frameworks which emphasize the importance of simplifying and
clarifying the intervention (91).
The use of costing and economic modeling of intervention
approaches to inform policy and resource allocation was
recommended by Milat et al. (93) as a strategy for successful
scale-up. However, it is notable that the evidence base does not
tend to take this into consideration. Only one study, Ferrer et al.
(48), looked at cost-effectiveness of CHPS compared to integrated
community case management (iCCM) to treat three infectious
diseases. None of the studies took a broader approach to assessing
costs and effectiveness across the range of primary care outcomes
that CHPS is designed to address. Several of the qualitative studies
highlighted the lack of resources within Ghana’s health sector as
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Elsey et al.
FIGURE 7
Barriers from qualitative studies.
a major limitation to the successful delivery of CHPS (35, 85).
The decrease in donor funding due to donor transitions has
compounded the funding challenges facing the CHPS programme.
Increasingly, this means that budgetary allocations to primary
health care and the CHPS programme from the Government
of Ghana are insufficient. With few countries on the continent
meeting the target of 15% of government expenditure on healthcare
as agreed in the Abuja Declaration of 2001 (3), these challenges
are common. However, the lack of government funding makes
CHPS increasingly reliant on internally generated funds from
the NHIS, out-of-pocket expenditure and funds from vertical
programs and projects. Each of these sources present significant
challenges to a strong health system-led by primary health care,
with out-of-pocket expenditure undermining accessibility and
vertical programmes leading to a focus on specific diseases rather
than the holistic needs of the patient (1).
Our findings highlight challenges with horizontal scale-up,
or increased adoption (in the language of RE-AIM), in certain
geographical contexts including remote rural areas and urban
areas. The challenges of delivering primary health care in remote
areas are well-covered in the literature, with poorly maintained
infrastructure, and a lack of supervision and managerial leadership
cited as leaving those working in primary health care demoralized
and suffering from burn-out (3). CHPS research, monitoring and
evaluation has traditionally focused on rural areas because of the
perception that Ghana’s major primary health care challenges were
rural. However, Ghana has evolved from a country that was 40%
urban when the Navrongo pilot was conducted in 1994-5. Current
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10.3389/fpubh.2023.1105495
estimates suggest over 57% of the population are now living in
urban areas (94), and with an estimated urban growth rate of 4.2%,
the urban population is expected to reach 65% by 2030 (7).
Increasingly questions arise as to how to adapt and deliver
primary health care systems developed for rural poor populations
to urban poor populations. This has led to increasingly attention
to urban primary care in research and policy (95, 96) with
findings pointing to the value of exploring different approaches
to structuring primary health care, including building linkages
between the plethora of private, informal and NGO providers
with the more limited public sector primary health care providers
(97). Developing strong community engagement and integration
of volunteers, which is a key feature of the CHPS model, is a
particular challenge in urban contexts. Strategies tried elsewhere
include moves to pay CHVs regular stipends, as recently agreed
in Kenya (98) and implemented in informal settlements in
Bangladesh through the Manoshi programme, where volunteers
receive financial incentives for each pregnancy identified or woman
that they accompany to a delivery center (99). The need to adapt
CHPS to fit the fast-evolving urban setting highlights a tension
between clearly specifying the programme—as typified by the 15
Steps—and being able to allow flexibility and adaptability.
4.1. Strengths and limitations
A strength of the review is the wide search strategy used to
identify both published and gray literature. However, given the
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Elsey et al.
diverse actors—NGOs, INGOs, donors, and researchers—who have
been involved with the CHPS programme since its inception, it is
likely that some evaluations will have been missed. Our systematic
use of the RE-AIM framework to categorize the qualitative studies
and to structure our synthesized findings is a further strength of
our review. The review team also acknowledged throughout the
review process that the use of the RE-AIM framework was at times
challenging as findings did not always fit neatly into the RE-AIM
domains. In particular, aspects of the context were hard to capture
within the RE-AIM framework and this may have undermined
insights in our synthesis.
4.2. Lessons for policy and practice
The review highlights the need to identify the resources
required to successfully implement CHPS within the different
socio-economic and socio-cultural contexts of Ghana. Clearly,
adequate resourcing and strategies to meet the financial
requirements of the programme are urgently needed. With
reducing donor funds, the role and functionality of NHIS and its
contributions to CHPS are of fundamental importance.
While the clarity of the steps needed to establish CHPS has
undoubtedly helped with scale up, flexibility and nimble responses
are needed in the context of rapid urbanization, health security in
the face of pandemics and the changing disease burden exhibited
within different contexts. The challenges of chronic diseases such
as hypertension and diabetes, poor mental health, tobacco, alcohol
and substance abuse are especially rife within urban populations,
thus health needs will differ from those in a more traditional CHPS
setting, and thus require a different approach. Ensuring that CHPS
is not pulled too far from its original focus on promotion and
prevention is particularly crucial given the increasing prevalence
of non-communicable diseases. The studies included that focus
on the urban context highlight the need to challenge assumptions
that urban populations are already well-served by primary care.
The predominant use of private, often unregulated health services
and the lack of prevention highlight the need for an urban-specific
CHPS model.
Keeping true to the original focus on community engagement
is key, however, creative thinking to respond to the changing types
of communities we find in rapidly urbanizing cities is needed.
This may involve linking with occupational community structures
such as market-traders associations or savings groups that are
active in poor urban neighborhoods in addition to engaging with
traditional leaders. Careful consideration of how to incentivize
engagement is required in the urban context where volunteer time
has a high opportunity cost. Given the rich history of evidence-
informed programme development that characterizes CHPS, it is
hoped that further research focusing on strategies to address the
financial, service provision and community engagement challenges
will continue to inform and improve CHPS.
5. Conclusions
The CHPS programme is built on a sound body of evidence,
and clear specification together with a conducive national
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10.3389/fpubh.2023.1105495
policy environment has aided scale-up. The combination of
community health nurses and volunteers, with significant
community engagement has been found effective in reducing
under five mortality, particularly for the poorest and least
educated, increasing the use and acceptance of family planning
and reducing the fertility rate. While it is clear that the CHPS
strategy can work for these rural populations in improving
these outcomes, effectiveness in urban contexts is yet to be
established. A clear specification of CHPS and a conducive national
policy environment has aided scale-up, with strong community
engagement, adequate resourcing and motivation for community
health workers proving key to successful implementation.
However, challenges to implementation and adoption across
Ghana remain, particularly in urban and remote rural areas where
these aspects are hard to deliver. Strengthened health financing
strategies, review of service provision in light of pandemics,
prevalence of non-communicable diseases and adaptation to
changing community contexts will be required for future successful
delivery and scale-up of CHPS.
Data availability statement
The original contributions presented in the study are included
in the article/Supplementary material, further inquiries can be
directed to the corresponding author.
Author contributions
HE, MA-O, AG, AA, AA-O, DD, EA, KA-W, and IA
developed the protocol and concept of the review. MA-O, HE,
AA, AG, AA-O, DD, EA, and KA-W screened and extracted data
from the included studies. HE, LW, AN, DA, and AG coded
qualitative findings. HE and DA synthesized qualitative findings.
AV and HE synthesized quantitative findings and conducted
the overall synthesis of results. HE drafted the manuscript
with support from NA. All authors read and approved the
final manuscript.
Funding
This review was funded as part of an MRC Health Systems
Development Award Grant Ref: MR/T022787/1.
Conflict of interest
The authors declare that the research was conducted
in the absence of any commercial or financial relationships
that could be construed as a potential conflict
of interest.
Publisher’s note
All claims expressed in this article are solely those
of the authors and do not necessarily represent those of
23 frontiersin.org
Elsey et al.
their affiliated organizations, or those of the publisher,
the editors and the reviewers. Any product that may be
evaluated in this article, or claim that may be made by
its manufacturer, is not guaranteed or endorsed by the
publisher.
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Supplementary material
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